|
|||||||
| Patient's Name |
|
Date | |||||
| Diagnosis | |||||||
| Physician's Signature | Phone | ||||||
| Compression (select one): | Products: |
No Substitution |
|||||
| 15-20 mmHg | Samson & Delilah | ||||||
| 20-30 mmHg | Cotton-, Truly Transparent-, Select Comfort- | ||||||
| 30-40 mmHg | Cotton-, Natural Rubber -, Select Comfort- | ||||||
| 40-50 mmHg | Natural Rubber |
Number of Refills______ |
|||||
| 50-60 mmHg | Natural Rubbert | ||||||
| Style (select one): | |||||||
|
|
|
|
|
|
|
| Calf | Pantyhose | Maternity Pantyhose | |||
|
Thigh |
Thigh with waste attachment Right Left |
Armsleeve with gauntlet without gauntlet |
|||
|
PHYSICIAN MEDICAL SUPPLY, INC. 6765 Lake Side Circle East Worthington, OH 43085 (419) 945-2980 Fax: (419) 945-2981 |
|
|
COMPRESSION LEVEL AT THE ANKLE |
INDICATIONS |
|
NOTE; ANY LEVEL CAN BE USED FOR TRAVEL ACCORDING TO DIAGNOSIS |
|
|
15-20
mmHg |
|
|
20-30
mmHg |
|
|
30-40
mmHg |
|
|
40-50
mmHg |
|
|
50-60
mmHg |
|
|
CONTRAINDICATIONS |
CAUTION |
|
|
|
|
|
No liability accepted for non-observance of contra-indications and cautions. * According to Widmer & Marshall |
||
![]() |
||
|
®=SIGVARIS is a registered trademark of Ganzoni & Cie AG, St. Gallen, Switzerland ©=2004 Ganzoni & Cie AG, St. Gallen, Switzerland |
||